Multiple Sclerosis Therapy

Covered Uses:	All FDA-approved indications not otherwise excluded from Part D. Additional off-label coverage is provided for treatment at the time of a first demyelinating event.
Exclusion Criteria:	Treatment of primary progressive MS is not covered. Combination therapy with a beta interferon product, Gilenya, or Copaxone is not covered.
Required Medical Information:	For relapsing forms of multiple sclerosis: Patient must still either be able to walk at least a few steps or alternatively must have some functional arm/ hand use consistent with performing activities of daily living. For Rebif only, patients must be already receiving Rebif or have experienced intolerance/failure with glatiramer (Copaxone), interferon beta-1b (Betaseron) or Interferon beta-1a (Avonex).
Age Restrictions:
Prescriber Restrictions:
Coverage Duration:	12 months
Other Criteria:

Last Modified on 12/19/2012